Healthcare Provider Details

I. General information

NPI: 1598726531
Provider Name (Legal Business Name): SHALOM PAIN TREATMENT MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 S ROBERTSON BLVD
LOS ANGELES CA
90035-1505
US

IV. Provider business mailing address

PO BOX 16713
BEVERLY HILLS CA
90209-2713
US

V. Phone/Fax

Practice location:
  • Phone: 818-497-3797
  • Fax: 310-860-1326
Mailing address:
  • Phone: 818-497-3797
  • Fax: 310-860-1326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA50982
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberA50982
License Number StateCA

VIII. Authorized Official

Name: KOUROSH NOORMAND
Title or Position: DIRECT OWNER
Credential: M.D.
Phone: 818-497-3797